Nigeria's mandatory health insurance and the march towards universal health coverage
Authors: Abiodun Awosusi
Journal: The Lancet Global Health (2022)

The 2022 Lancet Nigeria Commission highlights the value of adequate investments in health as Nigeria undergoes key transitions.1Abubakar I Dalglish SL Angell B et al.The Lancet Nigeria Commission: investing in health and the future of the nation.Lancet. 2022; 399: 1155-1200Summary Full Text Full Text PDF PubMed Scopus (42) Google Scholar It provides compelling evidence on the need for a “new social contract”1Abubakar I Dalglish SL Angell B et al.The Lancet Nigeria Commission: investing in health and the future of the nation.Lancet. 2022; 399: 1155-1200Summary Full Text Full Text PDF PubMed Scopus (42) Google Scholar between the people and the state. This contract is crucial for the implementation of the National Health Act (NHA), the National Health Insurance Authority (NHIA) Act, and national strategies and plans for health. On May 19, 2022, the National Health Insurance Authority Bill was signed into law: it makes health insurance mandatory for all citizens and legal residents.2Shehu G In bid to achieve universal coverage, President Buhari signs National Health Authority Bill into law.https://statehouse.gov.ng/news/in-bid-to-achieve-universal-coverage-president-buhari-signs-national-health-authority-bill-into-lawDate: May 19, 2022Date accessed: June 1, 2022Google Scholar It empowers the NHIA to be a more effective regulator and integrator. It also creates a mechanism to finance health-service delivery for the poor and vulnerable. The law is a product of decades of relentless efforts by multiple stakeholders and development partners. The 2014 NHA provides a mechanism to mobilise resources from public, private, philanthropic, and ancillary sources to finance access to a basic package of primary health care.1Abubakar I Dalglish SL Angell B et al.The Lancet Nigeria Commission: investing in health and the future of the nation.Lancet. 2022; 399: 1155-1200Summary Full Text Full Text PDF PubMed Scopus (42) Google Scholar State governments have been developing their primary health-care development agencies with support from the National Primary Health Care Development Agency. Recent evidence in the Lancet Global Health Commission on financing primary health care can support Nigeria's efforts to expand primary health-care coverage.3Hanson K Brikci N Erlangga D et al.The Lancet Global Health Commission on financing primary health care: putting people at the centre.Lancet Glob Health. 2022; 10: e715-e772Summary Full Text Full Text PDF PubMed Scopus (70) Google Scholar According to the 2018 Nigeria Demographic and Health Survey, only 3% of people aged 15–49 years have a form of health insurance coverage.4National Population CommissionICF2018 Nigeria Demographic and Health Survey. October 2019.https://www.dhsprogram.com/pubs/pdf/FR359/FR359.pdfDate: 2022Date accessed: July 3, 2022Google Scholar Inter-related political, socioeconomic, and cultural challenges have restricted uptake of health insurance. A new social contract is urgently needed to build trust in multiple health reforms, particularly implementation of NHA and NHIA Acts, as the NHIA and subnational governments seek to expand social health insurance schemes. The policy implementation context is more challenging: the socioeconomic effects of the COVID-19 pandemic, macroeconomic difficulties, and geopolitical challenges have resulted in limited fiscal space.5Amos OA Adebisi YA Bamisaiye A et al.COVID-19 and progress towards achieving universal health coverage in Africa: a case of Nigeria.Int J Health Plann Manage. 2021; 36: 1417-1422Crossref PubMed Scopus (8) Google Scholar Yet, the state should prioritise vital health investments and efficient use of public resources to harness the opportunities of an entrepreneurial, youthful population and an emerging middle class. One of the objectives of the NHIA is to ensure the participation of the private sector in health system reforms. Despite national, regional, and global constraints, multiple health enterprises are attracting investments from domestic and foreign players. As these enterprises evolve their value propositions, they can offer lessons to stakeholders on how to create a sustainable, value-based contract between citizens and service providers. The growth of these health enterprises is taking place within the context of rapid urbanisation, proposals for structural transformation, and private sector development that creates jobs for a youthful populace.6De Vries G Timmer M De Vries K Structural transformation in Africa: static gains, dynamic losses.J Dev Stud. 2015; 51: 674-688Crossref Scopus (115) Google Scholar There is also a continental push for integration of markets across Africa. Without undermining crucial public health investments, established and emerging health enterprises have a unique opportunity to contribute to local production of health products and delivery of high-quality health services that boost citizen trust. Outside the health sector, financial institutions and telecom service providers have key roles to play in Nigeria's universal health coverage journey: banks, financial technology companies, and their vast agent networks have multiple interface tools in the provision of financial services to the populace. More than 80% of Nigerians own a mobile phone, and the number of unique mobile subscribers is expected to rise from 97 million in 2018 to 130 million by 2025.7GSMA IntelligenceSpotlight on Nigeria: delivering a digital future.https://www.gsma.com/publicpolicy/wp-content/uploads/2019/02/GSMA-Spotlight-on-Nigeria-Report.pdfDate: 2018Date accessed: July 9, 2022Google Scholar Nigeria has more than 200 000 active mobile money agents across the country interacting with people close to their homes.8Sasu DD Number of mobile money agents in Nigeria: from 2016 – 2019.https://www.statista.com/statistics/1182039/number-of-mobile-money-agents-in-nigeriaDate: July 18, 2022Date accessed: July 20, 2022Google Scholar In addition to the work of specialised health professionals, community health institutions, professional associations, and the media, these agents represent a unique way to raise awareness about health insurance and facilitate uptake. Evidence suggests that elite negotiation and prioritisation of essential structural changes with pragmatic political settlements are crucial ingredients to enable the country to create a viable post-oil economy in which adequate health financing is prioritised.9Usman Z Economic diversification in Nigeria: the politics of building a post-oil economy. Bloomsbury Publishing, London, UK2022Crossref Google Scholar Besides, consistent health spending that addresses the unmet needs of the populace tends to boost political capital. The Lancet Nigeria Commission1Abubakar I Dalglish SL Angell B et al.The Lancet Nigeria Commission: investing in health and the future of the nation.Lancet. 2022; 399: 1155-1200Summary Full Text Full Text PDF PubMed Scopus (42) Google Scholar shows that health spending is an investment in economic growth, which then provides a favourable environment for higher health investments. One of the strategic objectives of the National Development Plan is human capital development: its implementation is expected to increase infrastructure investments and fast-track structural transformation in order to build a robust economy in which the contribution of the non-oil sector to gross domestic product and national revenue substantially increases.10Federal Ministry of FinanceBudget and National PlanningNational Development Plan 2021–2025.https://nationalplanning.gov.ng/wp-content/uploads/2021/12/NDP-2021-2025_AA_FINAL_PRINTING.pdfDate: 2021Date accessed: July 10, 2022Google Scholar The state should move progressively from commitment to action as available legal reforms provide new tools to address the unmet needs of the people. The new law represents a watershed moment in which institutional prioritisation of health investments, sustainable social contract, and fruitful private–private partnerships can accelerate Nigeria's progress towards health for all. I declare no competing interests. Finding balance in Nigeria's mandatory health insuranceThe question of sustainable financing for health-service delivery in Nigeria has been at the forefront of health discussions throughout the year.1 This discussion is against the backdrop of an overwhelming gap in health financing in the country,2 and its effect on the quality of Nigerian health-service delivery. The passage of the National Health Insurance Authority bill into law in May, 2022, making health insurance mandatory, and including a vulnerable group fund as one source of financial funding, has brought the question of health financing into sharper focus. Full-Text PDF Open Access